Thyroid Nodules
Triennial Course
Panel Discussion
October 2012
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Case 1:
• Currently 70 year old female remote history
breast cancer (1987), in remission
• In August 2005 palpable thyroid mass
detected at routine physical
• Asymptomatic. Normal thyroid function tests.
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Would you make underwriting decision here?
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Thyroid nodules
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From: Popoveniuc G and Jonklaas J. Thyroid Nodules. Med Clin N Am 96 (2012) 329-349.
Went to Surgery 2-8-06
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Case Discussion
• Breast cancer is one of few cancers that may metastasize to thyroid. Others include kidney, colon, and lung cancers.
• Her age 70 was risk factor.
• The likelihood of malignancy in multi-nodular thyroid gland is same as in single solitary nodule in normal thyroid gland.
• Selection of which nodule(s) for FNA is based on size, ultrasound appearance, growth pattern, or other suspicious characteristics.
• The left FNA was not diagnostic (inadequate specimen) and the right FNA was follicular neoplasm which had 20-30% likelihood of malignancy, which is what prompted surgery.
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Molecular assays
• Performed on Fine Needle Aspirate material
• Two available:
– AsuragenTM, molecular analysis for likely malignant
– VeracyteTM, molecular analysis for likely benign
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11Source: Paper Ad as appeared in JCEM Feb 2012 Vol 97 No. 2
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From: www.veracyte.com
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Alexander EK et al. Preoperative Diagnosis of Benign Thyroid
Nodules with Indeterminate Cytology NEJM 2012, June 25
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Gene
expression
classifier
Histology at
surgery,
malignant
(N = 85)
Histology at
surgery,
benign
(N = 180)
Suspicious 78 87
Benign 7 93
Prevalence of malignancy was 32%
Negative predictive value = 93%
Case 2:
• Currently age 49 year old female
• Family history of thyroid cancer in
grandmother
• Moved to USA from Eastern Europe 2001
• Seen 2009 for palpable thyroid nodule
• States had previous thyroid ultrasound in
2001
• Asymptomatic. Normal labs.
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5-2-09
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Thyroid nodules
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From: Popoveniuc G and Jonklaas J. Thyroid Nodules. Med Clin N Am 96 (2012) 329-349.
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Case 2 discussion
• Family history was important.
• Further detail on where Eastern Europe, may
have been important.
• FNA was cellular, increasing probability that
findings were true positive.
• Molecular assay role? Possibly to plan
surgical approach?
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Background Statistics, US population
• Prevalence palpable nodule about 4%
• Incidentally detected, 20-60%
population
• Thyroid cancer rates:
– 5.6/ 100,000 male
– 16.3/ 100,000 female
death rates
– thyroid cancer 0.6/100,000
population
• Distinguishing between benign
disease and malignant is goal of
clinical/ radiographic/ tissue
evaluationsImage from
www.nlm.nih.gov/medlineplus/thyroi
d
From: www.seer.cancer.gov/csr/1975_2009_pops0921
Evaluation
• Thyroid Stimulating Hormone (TSH)*
• Calcitonin
• Thyroid ultrasound
• Fine needle aspiration
– ?molecular assays
• Emerging technologies: elastography?
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*McLeod DS et al. Thyrotropin and thyroid cancer diagnosis: a systematic review and dose-
response meta analysis. JCEM Aug 2012 97(8):2682-2692.
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http://www.endocrineweb.com/conditions/thyroi
d/thyroid-gland-function
Radioactive Iodine Scan
Hot Nodule Cold Nodule
Suspicious radiographic features on ultrasound
• Micro-calcifications
• Hypoechogenicity
• Irregular margins
• Solid
• Intranodule vascularity
• More tall than wide
• Growth on serial studies
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From : Popoveniuc G and Jonklaas J. Thyroid Nodules. 2012 Med Clin N Am 96:329-349.
Risk factors for thyroid cancer
• Radiation exposure
• Age < 20 or > 60
• History goiter
• Family history thyroidal disease
• Male gender
• Family history multiple endocrine neoplasia-2, Cowden’s syndrome, familial polyposis, Carney complex, Werner’s
• Rapid growth, hoarseness, pain, nodule fixation
• Palpable cervical lymph nodes
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